Materi Kuliah Ards

5/19/2018 Materi Kuliah Ards

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Childrens Hospital of MichiganChildrens Hospital of Michigan

ACUTE RESPIRATORYDISTRESS SYDROME


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Childrens Hospital of Michigan

ISTI!AH !AI

Adult Respiratory

Distress SyndromeTransfusion LungPost Perfusion LungShock LungTraumatic Wet Lung


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ORI"IA! DE#IITIO Ac$te respirator% distress

C%anosis refractor% to o&%gentherap%

Decreased l$ng co'pliance

Di($se in)ltrates on chestradiograph

Di*c$lties+ lac,s speci)c criteria

contro-ers% o-er incidence and'ortalit%


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RE.ISIO O# DE#IITIOS

/011+ fo$r2point l$ng in3$r% score !e-el of PEEP

PaO45 #iO4ratio

Static l$ng co'pliance Degree of chest in)ltrates

/006+ consens$s conference

si'pli)ed the de)nition


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/006

COSESUS Ac$te onset'a% follo7 catastrophic e-ent

8ilateral in)ltrates on chestradiograph

PA9P : /1 '' Hg

T7o categories+

Ac$te !$ng In3$r% 2 PaO45#iO4ratio :;


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#ACTORS PECETUS

Shoc,

Aspiration of gastric contents

Tra$'a

Infections

Inhalation of to&ic gases and f$'es

Dr$gs and poisons


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STA"ES

Ac$te= e&$dati-e phase rapid onset of respirator% fail$re after

trigger

di($se al-eolar da'age 7ithin>a''ator% cell in)ltration

h%aline 'e'?rane for'ation

capillar% in3$r%

protein2rich ede'a >$id in al-eoli

disr$ption of al-eolar epitheli$'


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STA"ES

S$?ac$te= Proliferati-e phase+ persistent h%po&e'ia

de-elop'ent of h%percar?ia

)?rosing al-eolitis f$rther decrease in p$l'onar%

co'pliance

p$l'onar% h%pertension


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STA"ES

Chronic phase o?literation of al-eolar and ?ronchiolar

spaces and p$l'onar% capillaries

Reco-er% phase grad$al resol$tion of h%po&e'ia

i'pro-ed l$ng co'pliance resol$tion of radiographic a?nor'alities


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MORTA!ITY

6


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PATHO"EESIS

Inciting e-ent

In>a''ator% 'ediators

Da'age to 'icro-asc$lar endotheli$' Da'age to al-eolar epitheli$'

Increased al-eolar per'ea?ilit% res$ltsin al-eolar ede'a >$id acc$'$lation


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Patogenesis

D$a 'e,anis'e +

Aspirasi ?ahan ,i'ia ata$ inhalasi gas?er?aha%a langs$ng to,si, terhdp epitel al-eolar

epitel r$sa, dan ter3adi pening,atan

per'ia8I!ITAS

EDEMA ITERSTISIA!


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BERUSABA PADA MEM8RAA!.EO!OBAPI!ER

PEI"BATA PERMIA8I!ITAS

EDEMA ITERSTESIA!


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DUA MEBAISME ITU MEMPE"ARUHI +

2 TRASPORT "AS 'en$r$n

2 TIM8U! HIPOBSEMIA2 "A"A! APAS

2 PO4 : < ''Hg

2 PCO4 < ''Hg2 RR ;6 &5'nt

2 T. : cc5,g ??


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ORMA! A!.EO!US

Type I cell

Endothelial

Cell

RBCs

Capillary

Alveolar

macrophage

Type II

cell


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ACUTE PHASE O# ARDS

Type I cell

Endothelial

Cell

RBCs

Capillary

Alveolar

macrophage

Type II

cell

Neutrophils


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Kerusakan

alveoli saat

ards


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PATHOPHYSIO!O"Y

A?nor'alities of gas e&change

O&%gen deli-er% and cons$'ption

Cardiop$l'onar% interactions

M$ltiple organ in-ol-e'ent


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Sign and s%'pto'

A8ORMA!ITIES O# "AS ECHA"E Increased capillar% per'ea?ilit%

Interstitial and al-eolar e&$date S$rfactant da'age

Di($sion defect and right to left sh$nt


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Sign and s%'pto'

Stat$s 'ental 'en$r$n

Ta,i,ardi

Ta,ipnea dan d%spnea

Sianosis= p$cat

Retra,si notot napas

Ronchi ?asah pada ede'a p$l'onal,ardiogeni,

Analisa gas darah


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OXYEN EXTRACTION

!O"# $ % &' X ()*+ X ,-aO" . -vO"/

Arterial

In0lo1

,$/ capillary

O2

O2

O2

O2 O2

O2

O2

!enous

Out0lo1

,$/

Cell

O2

(Adapted from the ICU Book by P !arino"


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HEMODYNAMIC SUPPORT

2a% O"e%traction

Critical 3O"

!O"# 3O"X O"ER

3O"

!O"

Normal

2a% O"e%traction

Critical 3O"

A'normal 4lo1 3ependency

3O"

!O"

-eptic -hoc56AR3-


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OY"E DE!I.ERY FCOSUMPTIO

Pathologic >o7 dependenc%

Unco$pling of o&idati-e dependenc%

O&%gen $tiliGation ?% non2ATP prod$cingo&idase s%ste's

Increased di($sion distance for O4

?et7een capillar% and al-eol$s


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CARDIOPU!MOARYITERACTIOS

A P$l'onar% h%pertensionres$lting in increased R. afterload

8 Application of high PEEPres$lting in decreased preload

A8 Decreased cardiac o$tp$t


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RESPIRATORY SUPPORT

Conventional mechanical ventilation

Neer modalities!

"igh fre#uency ventilation

$nnovative strategies

Nitric o%ide

Li#uid ventilation &%ogenous surfactant


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MAA"EMET

Monitoring+

Respirator%

He'od%na'ic

Meta?olic5n$trition

Infections

#l$ids5electrol%tes


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MAA"EMET

Opti'iGe .O45DO4 relationship

Deli-er% O4 he'oglo?in 'echanical -entilation

o&%gen5PEEP

. ol$'e of O4 preload

afterload

contractilit%


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CONVENTIONAL VENTILATION'%ygen

P&&P$nverse $!& ratio

Loer tidal volume

(entilation in prone position


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RESPIRATORY SUPPORT

)oal! maintain sufficient o%ygenation andventilation* minimi+e complications of ventilatorymanagement

$mprove o%ygenation! P&&P* ,AP* -i'. $mprove ventilation ! change in pressure


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Mechanical Ventilation GuidelinesAmerican College of Chest Physicians/

Consensus Conference 0112

)uidelines for ,echanical (entilation in ARDS

When possi3le* plateau pressures 4 25 cm ".'

Tidal volume should 3e decreased if necessary

to achieve this* permitting increased pC'.


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PEEP !ene"its

$ncreases transpulmonary distending pressure

Displaces edema fluid into interstitium

Decreases atelectasis Decrease in right to left shunt

$mproved compliance

$mproved o%ygenation


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No !ene"it to Ea#l$ A%%lication o"

PEEPPepe P& et al6 N&7, 0189:200!.80;. hours

No differences in development of ARDS*

complications* duration of ventilation* time inhospital* duration of $C? stay* mor3idity or mortality


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P#essu#econt#olled Ventilation

&PCV'Time;cycled mode

Appro%imate s#uare aves of a preset pressure are

applied and released 3y means of a decelerating flo,ore laminar flo at the end of inspiration

,ore even distri3ution of ventilation in patients ith

marked different resistance values from one region of

the lung to another


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P#essu#econt#olled In(e#se#atio

VentilationConventional inspiratory;e%piratory ratio is reversed

@$!& .!0 to 2!0

Longer time constantBreath starts 3efore e%piratory flo from prior 3reath

reaches 3aselineauto;P&&P ith recruitment ofalveoli

Loer inflating pressures

Potential for decrease in cardiac output due to increasein ,AP


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HASIL PENELITIAN

$n patients ith acute lung inury and the acute

respiratory distress syndrome* mechanical ventilationith a loer tidal volume than is traditionally used

results in decreased mortality and increases the num3er

of days ithout ventilator use


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P#one Position

$mproved gas e%change

,ore uniform alveolar ventilation

Recruitment of atelectasis in dorsal regions$mproved postural drainage

Redistri3ution of perfusion aay from edematous*

dependent regions


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#$A%K &O' A

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